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SAN JOAQUIN COUNTY <br /> / 9 J�-, ENVIRONMENTAL HEALTH DEPARTMENT <br /> , 5WZtton,CA 95202-2708 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspectio Date: <br /> �Z i C a2 -f- Sc�nl 'L" L. S 36/0-7 <br /> Facility Address: Service Request#: <br /> 0 Fr-A,-J e wer f- cf�-� S�6�cc / S2Dv S' 631 (q <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Certification#: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector 0 Spill bucket XZminimum 5 gallon <br /> El electronic Serial❑ ❑ mechanical erial#: j KI hour hydrostatic ElIncon TS-STS <br /> ❑ Caldwell System ❑ Other <br /> El line test ro rammed <br /> Leak detector W46 <br /> ❑ mechanical Model: Spill bucket ,$t minimum 5 gallon <br /> ❑ ❑ electronic Serial #: �Z1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor <br /> ❑ <br /> El shutdown Model: ElPrimary piping testing at: <br /> si <br /> El fail safe Serial#: p <br /> El NA minutes <br /> sensor <br /> ❑ <br /> El positive shutdown Model: ElSecond psi piping testing at: <br /> [I fail safe Serial #: <br /> El NA minutes <br /> sensor Secondary containment repairs for: <br /> ❑ ❑ positive shutdown Model: ❑ UDC(s) Piping <br /> ❑ fail safe Serial #: Sump(s) UST(s) <br /> ❑ NA <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> ❑ Overfill prevention (see LG letter 150-1) Other: see below <br /> S cp/V tiG Tyr,*-z,/ t o i CNj v.-A d <br /> v� ,l <br /> 1"L. (Yv <br /> zVeAo 1A 4 S/wa nuctak— iuir 1 AF b-,(69- ok h yfe., <br /> THIS FACILITY S'SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Received By: Title: <br /> EHD 23-04 <br /> 1/3/07 <br />